Negligent and imprecise responses to residents' incontinence carry a heavy price-here's how not to pay for it
BY LEAH KLUSCH As I walked down the hall of the facility, a resident caught my eye. She was bright-eyed, very thin, well dressed in day clothes, standing in the doorway of a room. She appeared confused and upset, and she was seeking my attention. As I approached her, our eyes met-she needed something. And then I glanced to the floor. Around her ankles was an incontinence brief. "What do I do?" she said. "It fell off. I can't walk." My heart was breaking, and my clinical mind was racing. "Let me help you," I said-and in my heart I was saying, "Let me help you out of this mess! Who did this to you? How did this happen?"
As I assisted her in stepping out of the brief (not a procedure found in most nursing home manuals), I looked for another brief and found only a pair of extra-large briefs in the bathroom-no panty liners or other products. I asked the resident to sit in the chair on the open brief, checked that she did not need to use the toilet, and told her I would be back in a moment. I went to find the caregiver or a nurse to assist me. I needed to know what product to use or what assistance the resident needed, as well as to document the event.
"What if this were my mother, sister, friend, or aunt," I thought. "How would I feel? How does this resident feel?" The look in her eyes when our eyes met in that hallway, her injured sense of dignity and self-esteem, the fear.... I was able to find the caregiver, return to the resident's room, and locate appropriate products, both in size and type, to make her comfortable.
I have never forgotten her image in the doorway.
All long-term care facilities need to view urinary incontinence as a prevalent condition that requires operational, clinical, strategic, and interdisciplinary focus. Costs of incontinence to the facility can include absorbent products, laundry, and increases in staff workload. There are also negative clinical, psychosocial, payment, and regulatory outcomes, as well as negative resident events such as falls, urinary tract infections, skin breakdown, depression, and repeated hospitalizations.
The numbers vary, but high percentages of residents are incontinent, even though urinary incontinence is not necessarily a normal part of aging. However, the American Medical Directors Association (AMDA) clinical practice guidelines state that the prevalence of urinary incontinence increases with age and affects women more than men. It can be treated, modified, managed, and cured-even in frail elderly individuals-although the cost of treating it is staggering: as high as $25 billion annually.
Incontinence is identified by observation or direct reporting from the resident. All involuntary loss of urine, including bed-wetting, is considered incontinence. The MDS 2.0 Users' Manual (December 2002), Chapter 3, Section H, states: "If the resident's skin gets wet with urine, or if whatever is next to the skin (i.e., pad, brief, underwear) gets wet, it should be counted as an episode of incontinence-even if it is just a small volume of urine, for example, due to stress incontinence."
Most facilities are not, in fact, identifying residents with small to moderate amounts of urine loss caused by various types of incontinence (table 1). The current MDS database shows a much lower than expected number of residents coded with incontinence. If a resident is not identified appropriately as incontinent, then the care plan is wrong, and planned care interventions will not be adequate to meet the resident's needs.
Managing incontinence is not just a clinical or nursing care issue. Other factors come into play, such as the resident's history. Is it an old problem or a new problem? What was the impact of the hospital stay on the resident's continence? A significant number of residents come to post-acute care facilities with a loss of bladder control because of the use of catheters in the hospital. Placement of an indwelling catheter during hospitalization or repeated catheterizations during a hospital stay can bruise, stretch sphincters, or cause other trauma to very delicate tissues.
Can we improve the resident's ability to toilet independently or with minimal assistance? Restorative nursing programs need to be involved in initiating proper bladder retraining and toileting programs and then must monitor the programs as residents' function improves. A properly designed retraining or scheduling program requires the involvement of the entire team and must be evaluated by professionals with significant education in this area. The use of consultants is important in this field, especially since new programs, research, and interventions are being developed all the time. Individualization of the program is essential, and communication of the interventions to the resident must be clear and easy to understand.
If the resident needs absorbent products, what is the best product to use? It is important to realize that some residents need more than one type of product during the day and night, and that all residents come in varying shapes and sizes. Table 2 includes factors to consider when choosing a supplier for these products.
Research in this field has identified several guidelines for appropriately managing incontinence in the nursing home (see "Recommended Guidelines,").
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